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Background: More than 97% of febrile infants and young children have self-limiting viral infection and therefore, would not require antibiotics. Over prescription of antibiotics increases antibiotics exposure and development of resistance among patients. There is need to evaluate empiric antibiotic prescription in order to limit its use to only febrile children with bacterial infection. Aim and Objectives: The aim of this study was to determine the prevalence of empiric antibiotic prescription among febrile underfive, post neonatal children presenting in the children outpatient clinic of the University of Port Harcourt teaching hospital. Method: Febrile Children aged 29 days to 0.05). Upper respiratory tract infection (83.7 %) and diarrhea (55.9%) were significantly associated with empiric antibiotic prescription (P=0.05 and 0.002 respectively). Conclusion: Empiric antibiotic prescription for febrile under-five children is a common practice in UPTH. Physicians should therefore reduce the frequency of antibiotics prescription in febrile children unless there is clinical evidence of bacterial infection.

Background Early initiation of appropriate antibiotics is key to the effective management of severe bacterial infections. The initiation of targeted antibiotic therapy is possible only when the causative organism is isolated. As a result, antibiotics are usually administered on an empirical basis guided by the clinical presentation, local antibiotic guidelines and other relevant histories. Generally, empirical antibiotics differ for both community- and hospital-acquired infections (HAIs), as a result of which common HAI pathogens such as Pseudomonas aeruginosa should be deliberately targeted, because most routine antibiotics are ineffective against them. Methodology: This was a retrospective cross-sectional study involving the review of the clinical consults sent to clinical microbiologists at the University of Benin Teaching Hospital (UBTH) between January and December 2022. The consults were analyzed for the initial diagnosis, reasons for the invitation and empirical antibiotics administered. Other relevant informations were obtained from the laboratory records. Susceptibility profiles of P. aeruginosa isolates were compared with the empirical antibiotics administered. Discordant empirical antibiotic therapy was defined as the administration of antibiotic regimen with no anti-pseudomonal activity. Results: Of the 256 consults received over the period of study, P. aeruginosa was isolated from 57 (22.3%) patients as pathogens. Out of this, 24.6% (n=14) received at least one anti-pseudomonas antibiotic, which puts the total discordant rate at 75.4%. Metronidazole (22.7%) and ceftriaxone-sulbactam (Tandak) (21.5%) were the most commonly prescribed empirical antibiotics. The most common reason for consultation was a diagnosis of sepsis at 40.2% followed by pan-resistant isolates at 34.8%. Conclusion: Although the commonly prescribed antibiotics in our setting are broad spectrum, they lack coverage for P. aeruginosa which is one of the most common pathogens implicated in HAIs. [ABSTRACT FROM AUTHOR]

Background: Prior studies suggest associations between receipt of piperacillin-tazobactam and development of acute kidney injury and receipt of anti-pseudomonal cephalosporins and neurotoxicity. We compared clinically-relevant renal and neurologic outcomes in critically ill patients who received piperacillin-tazobactam versus anti-pseudomonal cephalosporins. Methods: We conducted a secondary analysis of data from the Isotonic Solutions and Major Adverse Renal Events Trial examining patients who received piperacillin-tazobactam or an anti-pseudomonal cephalosporin within 24 h of intensive care unit admission. We performed multivariable analysis using a proportional odds model to examine the association between the first antibiotic received and the outcomes of Major Adverse Kidney Events within 30 days (MAKE30) and days alive and free of delirium and coma to day 28. Results: 3199 were included in the study; 2375 (74%) receiving piperacillin-tazobactam and 824 (26%) receiving anti-pseudomonal cephalosporin. After adjustment for prespecified confounders, initial receipt of piperacillin-tazobactam, compared to anti-pseudomonal cephalosporins, was not associated with higher incidence of MAKE30 (adjusted odds ratio, 1.03; 95% CI, 0.83-1.27; P =.80) but was associated with a greater number of days alive and free of delirium and coma (adjusted odds ratio, 1.18; 95% CI, 1.00-1.38; P =.04). In a sensitivity analysis adjusting for baseline receipt of medications which may impact neuro function, this finding was not significant. Conclusion: Among critically ill adults, receipt of piperacillin-tazobactam was not associated with an increased incidence of death, renal replacement therapy, or persistent renal dysfunction or a greater number of days alive and free of delirium and coma. Randomized trials are needed to inform the choice of antibiotics for empiric treatment infection in critically ill adults. [ABSTRACT FROM AUTHOR]

Postoperative incisional concerns including nonpurulent drainage are relatively common following spine surgery. Evidence-based management protocols are lacking. The purpose of this study is to determine if prescribing empiric oral antibiotics for nonpurulent wound drainage is beneficial for the prevention of chronic infection or reoperation. Retrospective chart review. Patients calling the office with postsurgical wound concerns. Not applicable. In a large, multisurgeon, spine surgery practice, a review of the communications log showed that 298 patients called or messaged the office with a concern regarding postoperative nonpurulent wound drainage. Patients were prescribed empiric oral antibiotics based on surgeon preference. Patients who received empiric oral antibiotic treatment (AbxTx) were propensity matched to patients who did not (No AbxTx) based on sex, age, BMI, ASA grade, smoking status, prior spine surgery, anatomic location, and number of surgical levels. The number of patients requiring surgical intervention (debridement) and/or developing a chronic infection was determined. Oral antibiotics were prescribed for 112 of the 298 (38%) patients with reports of nonpurulent drainage. Demographic and surgical characteristics of the two matched cohorts were similar. Although there were more patients in the AbxTx group who required surgical intervention (n=17, 17%) compared to the No AbxTx group (n=9, 9%), this difference was not statistically significant (p=.139). The intra-operative culture results showed no growth in 94% (16/17) of the AbxTx group vs 67% (6/9) of the No AbxTx group (p=.103). One patient in each group required a return to the operating room within the year after the initial surgical debridement for management of chronic infection. In this large series (n=298) of patients with nonpurulent wound drainage following spine surgery, 87% resolved without the need for surgical intervention. Empiric oral antibiotics did not reduce the need for surgical intervention or the development of a chronic infection. In addition to the added cost, potential adverse reactions, development of resistant organisms, and inaccurate labeling of surgical site infection; empiric oral antibiotics may lead to a negative intraoperative culture for those requiring surgical intervention impacting the ability to prescribe a specific antibiotic regimen. [ABSTRACT FROM AUTHOR]

Based on in vitro susceptibilities and the concern for emergence of resistance and long-term safety, ampicillin plus gentamicin remains the recommended antibiotic regimen for early onset neonatal sepsis. Our objective was to identify potential limitations of this regimen based on clinical and pathogen characteristics while minimizing risks associated with prolonged antibiotic exposure. We identified 43 gram-negative pathogens in 42 patients. Escherichia coli (E coli) occurred in 50% and Streptococcus agalactiae in 23.8% of patient. Ampicillin resistance was common, particularly in E coli (85.7%). Mortality was 23.8%, all due to E coli. We found that E coli is the most frequent pathogen and has a high mortality particularly in neonates < 1500 g; mortality is high with the current dosing strategy when E coli is resistant to ampicillin even when sensitive to gentamicin; resistance to gentamicin remains low but seems to be increasing while resistance to third-generation cephalosporins remains very low. [ABSTRACT FROM AUTHOR]

BACKGROUND: Appropriate empiric antibiotics for use in patients with febrile neutropenia (FN) must balance adequate coverage per the local antibiogram and patient factors (eg, a history of treatment resistance, clinical presentation), as well as the principles of antimicrobial stewardship. Based on the antibiogram reporting of poor susceptibility of Pseudomonas aeruginosa to cefepime, our institution requires the addition of empiric treatment with tobramycin for 48 hours (or longer if there is growth of a gram-negative organism) for the initial management of FN. A paucity of data exists regarding a dual antipseudomonal treatment strategy in this setting. OBJECTIVE: To evaluate the adherence to institutional protocol and the efficacy and safety of tobramycin added to the antipseudomonal ß-lactam antibiotic cefepime for the empiric treatment of FN in adults with cancer versus patients who did not receive dual-coverage therapy with cefepime and tobramycin. METHODS: In this retrospective study, we determined adherence to institutional protocol in adults with FN who required empiric treatment with cefepime plus at least 48 hours of concomitant treatment with tobramycin at Augusta University Medical Center between January 1, 2019, and July 31, 2020. The patients were divided into 3 cohorts according to the treatment they received, including cefepime monotherapy, tobramycin within 48 hours of treatment with cefepime per the institution's protocol (ie, early dual therapy), and tobramycin after 48 hours of cefepime treatment (ie, delayed dual therapy). The secondary end points included length of stay (LOS) in the hospital and intensive care unit (ICU), the incidence of gram-negative and cefepime-resistant bacteremia and any gram-negative infection, acute kidney injury (AKI), and in-hospital mortality. To analyze the statistics, we used logistic regression, chi-square testing, or nonparametric testing. RESULTS: Of the 350 study patients who received cefepime for FN, 185 (53%) received cefepime monotherapy, 146 (42%) received early dual therapy, and 19 (5%) received delayed dual therapy. The demographics were similar among the cohorts, except the cefepime monotherapy group had fewer patients with a hematologic disorder or bone marrow transplant, fewer patients who received concomitant treatment with vancomycin, and fewer patients with hypotension. No significant differences were found among the groups in the incidences of gram-negative bacteremia or any gram-negative infection, AKI, ICU admission, or LOS in the ICU (all P>.05). The patients in the cefepime monotherapy cohort had a shorter hospital LOS (6±9.6 days) than the patients who received early dual therapy (15±12.1 days) or delayed dual therapy (22±14.1 days). Mortality was lower in the cefepime monotherapy cohort than in the delayed dual-therapy cohort (P=.01). CONCLUSIONS: The addition of tobramycin to cefepime treatment in adults with FN did not significantly improve the patients' outcomes. [ABSTRACT FROM AUTHOR]

Neonatal sepsis is a significant cause of mortality and morbidity in low- and middle-income countries. To deliver high-quality data studies and inform future trials, it is crucial to understand the challenges encountered when managing global multi-centre research studies and to identify solutions that can feasibly be implemented in these settings. This paper provides an overview of the complexities faced by diverse research teams in different countries and regions, together with actions implemented to achieve pragmatic study management of a large multi-centre observational study of neonatal sepsis. We discuss specific considerations for enrolling sites with different approval processes and varied research experience, structures, and training. Implementing a flexible recruitment strategy and providing ongoing training were necessary to overcome these challenges. We emphasize the attention that must be given to designing the database and monitoring plans. Extensive data collection tools, complex databases, tight timelines, and stringent monitoring arrangements can be problematic and might put the study at risk. Finally, we discuss the complexities added when collecting and shipping isolates and the importance of having a robust central management team and interdisciplinary collaborators able to adapt easily and make swift decisions to deliver the study on time and to target. With pragmatic approaches, appropriate training, and good communication, these challenges can be overcome to deliver high-quality data from a complex study in challenging settings through a collaborative research network. [ABSTRACT FROM AUTHOR]

Introduction: Recent trials have shown early de-escalation of empiric antimicrobial therapy (EAT) in febrile neutropenia has led to less adverse effects with no difference in patient mortality. In 2019, our institution adjusted internal guidelines to de-escalate EAT after 7 days of intravenous anti-pseudomonal therapy in patients with signs of clinical recovery from febrile neutropenia and no evidence of infection. Methods: This was a retrospective, single-center, observational, cohort study. Eligible patients were adults with acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL) who received induction chemotherapy and developed febrile neutropenia without documented infection. Patients were separated based on EAT duration: ≤ 9 days and > 9 days. Empiric antimicrobial therapy was defined as the initiation of an anti-pseudomonal beta-lactam. The primary outcome was the difference in number of EAT-free days. Secondary outcomes included fever recurrence, ICU admissions, fever duration, infections post de-escalation, and Clostridioides difficile infection (CDI). Results: Forty-four encounters met inclusion. The EAT ≤ 9 days group had 7 more EAT-free days compared to the EAT > 9 days group (p < 0.001). No between-group differences were identified in terms of fever after EAT discontinuation (p = 0.335), ICU admission (p = 0.498), or CDI (p = 0.498). The EAT > 9 days group experienced longer initial fever (p < 0.001) and received addition of resistant Gram-positive coverage (p = 0.014). More patients receiving EAT > 9 days had a diagnosis of AML (p = 0.001). Conclusions: Shorter EAT duration did not lead to worse outcomes in patients with AML or ALL who received induction chemotherapy and developed febrile neutropenia without a documented infection source. [ABSTRACT FROM AUTHOR]

Background: Empiric antibiotics are often prescribed in critically ill and preterm neonates at birth until sepsis can be ruled out. Although the current guideline suggests narrow-spectrum antibiotics, an upgrade in antibiotics is common in the neonatal intensive care unit. The impacts of initial broad-spectrum antibiotics on the outcomes of critically ill neonates with respiratory failure requiring mechanical intubation have not been well studied. Methods: A total of 1162 neonates from a tertiary level neonatal intensive care unit (NICU) in Taiwan who were on mechanical ventilation for respiratory distress/failure at birth were enrolled, and neonates receiving ampicillin plus cefotaxime were compared with those receiving ampicillin plus gentamicin. Propensity score-matched analysis was used to investigate the effects of ampicillin plus cefotaxime on the outcomes of critically ill neonates. Results: Ampicillin plus cefotaxime was more frequently prescribed for intubated neonates with lower birth weight, higher severity of illness, and those with a high risk of early-onset sepsis. Only 11.1% of these neonates had blood culture-confirmed early-onset sepsis and/or congenital pneumonia. The use of ampicillin plus cefotaxime did not significantly contribute to improved outcomes among neonates with early-onset sepsis. After propensity score-matched analyses, the critically ill neonates receiving ampicillin plus cefotaxime had significantly worse outcomes than those receiving ampicillin plus gentamicin, including a higher risk of late-onset sepsis caused by multidrug-resistant pathogens (11.2% versus 7.1%, p = 0.027), longer duration of hospitalization (median [IQR], 86.5 [47–118.8] days versus 78 [45.0–106.0] days, p = 0.002), and a significantly higher risk of in-hospital mortality (14.2% versus 9.6%, p = 0.023). Conclusions: Ampicillin plus cefotaxime should not be routinely prescribed as the empiric antibiotics for critically ill neonates at birth because they were associated with a higher risk of infections caused by multidrug-resistant pathogens and final worse outcomes. [ABSTRACT FROM AUTHOR]

Neonatal sepsis is a significant cause of mortality and morbidity in low- and middle-income countries. To deliver high-quality data studies and inform future trials, it is crucial to understand the challenges encountered when managing global multi-centre research studies and to identify solutions that can feasibly be implemented in these settings. This paper provides an overview of the complexities faced by diverse research teams in different countries and regions, together with actions implemented to achieve pragmatic study management of a large multi-centre observational study of neonatal sepsis. We discuss specific considerations for enrolling sites with different approval processes and varied research experience, structures, and training. Implementing a flexible recruitment strategy and providing ongoing training were necessary to overcome these challenges. We emphasize the attention that must be given to designing the database and monitoring plans. Extensive data collection tools, complex databases, tight timelines, and stringent monitoring arrangements can be problematic and might put the study at risk. Finally, we discuss the complexities added when collecting and shipping isolates and the importance of having a robust central management team and interdisciplinary collaborators able to adapt easily and make swift decisions to deliver the study on time and to target. With pragmatic approaches, appropriate training, and good communication, these challenges can be overcome to deliver high-quality data from a complex study in challenging settings through a collaborative research network.

Purpose of Review: Early antibiotic administration is the cornerstone of sepsis treatment guidelines and quality measures. We summarize recent key literature on sepsis definitions and screening, time-to-antibiotics and outcomes, and dosing considerations. Recent Findings: Current sepsis clinical criteria have limited utility for identifying patients who warrant urgent broad-spectrum antibiotics because they include a very heterogeneous population, including many patients later found to have non-infectious syndromes or mild transient illnesses. The best available evidence supports immediate antibiotic administration (within 1 h) for patients with septic shock. Many sepsis patients without shock likely benefit from early antibiotics as well, but further high-quality studies are needed to precisely delineate the magnitude of benefit among potential subgroups and the time windows beyond which delays lead to worse outcomes. Time from antibiotic order-to-infusion and the order of antibiotic administration (i.e., beta-lactam before vancomycin) are two additional care processes found to be associated with outcomes. Empiric antibiotic choices should be informed by patients' likely site of infection, prior microbiology, comorbidities, severity of illness, and allergy profiles, and the development of better antibiotic resistance predictive models and novel rapid antimicrobial susceptibility testing hold promise for mitigating risks of both inadequate and unnecessarily broad antibiotic therapy. Lastly, incorporating established pharmacokinetic and pharmacodynamic principles, including aggressive loading doses and prolonged beta-lactam infusions, is critical to optimize clinical outcomes. Summary: A systematic approach to deciding who needs early versus immediate antibiotics, which agents to choose, and how to properly dose them may improve sepsis outcomes while minimizing antibiotic-related adverse events. [ABSTRACT FROM AUTHOR]

Endalkachew Mekonnen Eticha,1 Workineh Diriba Gemechu2 1Ambo University, College of Medicine and Health Science, School of Pharmacy, Ambo, Ethiopia; 2Jigjiga University, College of Medicine and Health Science, School of Medicine, Jigjiga, EthiopiaCorrespondence: Endalkachew Mekonnen Eticha Email obsaamiiraa@gmail.comObjective: The high incidence and substantial morbidity and mortality associated with community-acquired pneumonia necessitate an accurate assessment and appropriate management of patients. This observational prospective study aimed to evaluate the physicians’ adherence to the Ethiopian Standard Treatment Guideline for assessment and an empiric antibiotic selection for Community-acquired pneumonia.Results: The study indicated that the pneumonia severity assessment tool, CURB-65 score, was never used. Of 141 patients referred to an admitting diagnosis of severe community-acquired pneumonia, only 50 were subsequently found to satisfy the guideline criteria, over-diagnosis of 41.9%. Large proportions of the participants (130, 60%) were prescribed antibiotics in the last three months. The most commonly prescribed single antibiotic was Ceftriaxone (47, 21.7%), while ceftriaxone plus azithromycin was the most common combination, 110 (50.7%). In general, the extent of non-adherence to the national guideline for the use of antibiotics was 36.4%. In conclusion, the use of CRB65 scores was uncommon in the study setting. Poor adherence to Ethiopian Standard Treatment Guideline regarding the decision of hospital admission (41.9%) and the antimicrobial selection (36.4%) was determined.Keywords: standard treatment, adherence, empiric antibiotics, community-acquired pneumonia

Increasing antibiotic resistance to WHO-recommended first- and second-line treatments of pediatric sepsis requires adaptation of prescribing guidelines. We discuss the potential and limitations of a weighted-incidence syndromic combination antibiogram (WISCA) as a practical tool for incorporating local microbiology data when assessing empiric coverage of commonly used antibiotics. A brief questionnaire of 18 clinically significant isolates from pediatric blood cultures (Jan-Dec 2018) was sent to a global network of pediatric hospitals in July 2019. Weighted coverage estimates of non-antipseudomonal third-generation cephalosporins (3GC) and meropenem were estimated using Monte–Carlo simulation for each site reporting >100 isolates. 52 hospitals in 23 countries in 5 WHO regions responded to the questionnaire; 13 sites met the sample size requirement. The most common isolates were S. aureus, Klebsiella spp., E. coli and Enterococcus spp. Coverage of 3GC ranged from 39% [95%CrI: 34–43%] to 73% (two sites: [95%CrI: 65–80%]; [95%CrI: 68–86%]) and meropenem coverage ranged from 54% [95%CrI: 47–60%] to 88% [95%CrI:84–91%]. A WISCA is a data-driven, clinically intuitive tool that can be used to compare empiric antibiotic regimens for pediatric sepsis using existing large datasets. The estimates can be further refined using more complex meta-analytical methods and patient characteristics. [ABSTRACT FROM AUTHOR]

It is well established that Intensive Care Units (ICUs) are a focal point in antimicrobial consumption with a major influence on the ecological consequences of antibiotic use. With the high prevalence and mortality of infections in critically ill patients, and the clinical challenges of treating patients with septic shock, the impact of real life clinical decisions made by intensivists becomes more significant. Both under- and over-treatment with unnecessarily broad spectrum antibiotics can lead to detrimental outcomes. Even though substantial progress has been made in developing rapid diagnostic tests that can help guide antibiotic use, there is still a time window when clinicians must decide the empiric antibiotic treatment with insufficient clinical data. The continuous streams of data available in the ICU environment make antimicrobial optimization an ongoing challenge for clinicians but at the same time can serve as the input for sophisticated models. In this review, we summarize the evidence to help guide antibiotic decision-making in the ICU. We focus on 1) deciding IF: to start antibiotics, 2) choosing the spectrum of the empiric agents to use, and 3) de-escalating the chosen empiric antibiotics. We provide a perspective on the role of machine learning and artificial intelligence models for clinical decision support systems that can be incorporated seamlessly into clinical practice in order to improve the antibiotic selection process and, more importantly, current and future patients' outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background Septic arthritis of digits needs urgent treatment. When treatments delayed or insufficient, patients may be referred to the upper-level hospital due to uncontrolled infection. We reviewed the treatment history of referred patients and compared the microorganisms and the clinical course of both primary and referred patients as relevant studies are rare. Methods In this retrospective review of consecutive case series, 45 patients (primary, n = 11; referred, n = 34) were treated with multiple irrigation and debridement. Cefazolin was used as empiric antibiotics, then changed according to microbiologic study. Previously used antibiotics, treatment delay, surgical history of the referred patients were reviewed. Identified microorganisms, required surgical intervention, hospital stay, radiologic outcome, functional outcomes were compared between both groups. Results In the referred patients, methicillin-resistant Staphylococcus aureus (MRSA) was commonly found and cefazolin was susceptible in only 15% of the cases. Longer hospital stay, prolonged antibiotic therapy, more surgical intervention including flap surgery was required to treat the referred patients. Postoperative pain was not severe in daily activities, but the final range of motion was significantly less in the referred patients compared to the primary patients. Conclusions This study suggests that in the treatment of uncontrolled septic arthritis of the digits, antibiotic agents covering MRSA may shorten the duration of antibiotic therapy in areas of high MRSA incidence. Besides, more number of I & D including flap surgery may be required for the referred patients compared with the primary patients. These findings can help the surgeon in setting up a treatment plan or in counseling of referred patients with uncontrolled septic arthritis of the digits.

Background: Empiric antibiotics are often prescribed in critically ill and preterm neonates at birth until sepsis can be ruled out. Although the current guideline suggests narrow-spectrum antibiotics, an upgrade in antibiotics is common in the neonatal intensive care unit. The impacts of initial broad-spectrum antibiotics on the outcomes of critically ill neonates with respiratory failure requiring mechanical intubation have not been well studied. Methods: A total of 1162 neonates from a tertiary level neonatal intensive care unit (NICU) in Taiwan who were on mechanical ventilation for respiratory distress/failure at birth were enrolled, and neonates receiving ampicillin plus cefotaxime were compared with those receiving ampicillin plus gentamicin. Propensity score-matched analysis was used to investigate the effects of ampicillin plus cefotaxime on the outcomes of critically ill neonates. Results: Ampicillin plus cefotaxime was more frequently prescribed for intubated neonates with lower birth weight, higher severity of illness, and those with a high risk of early-onset sepsis. Only 11.1% of these neonates had blood culture-confirmed early-onset sepsis and/or congenital pneumonia. The use of ampicillin plus cefotaxime did not significantly contribute to improved outcomes among neonates with early-onset sepsis. After propensity score-matched analyses, the critically ill neonates receiving ampicillin plus cefotaxime had significantly worse outcomes than those receiving ampicillin plus gentamicin, including a higher risk of late-onset sepsis caused by multidrug-resistant pathogens (11.2% versus 7.1%, p = 0.027), longer duration of hospitalization (median [IQR], 86.5 [47–118.8] days versus 78 [45.0–106.0] days, p = 0.002), and a significantly higher risk of in-hospital mortality (14.2% versus 9.6%, p = 0.023). Conclusions: Ampicillin plus cefotaxime should not be routinely prescribed as the empiric antibiotics for critically ill neonates at birth because they were associated with a higher risk of infections caused by multidrug-resistant pathogens and final worse outcomes.

Background: Vancomycin plus piperacillin-tazobactam (VPT) is a commonly used empiric combination of antimicrobials. Recently, studies have demonstrated an increase in acute kidney injury (AKI) associated with combination therapy of VPT. However, the majority of studies required patients to be on VPT for a minimum of 48 to 72 hours to be considered for inclusion and had extended treatment durations longer than most empiric, short course regimens. Objective: To assess the incidence of AKI in noncritically ill patients being treated with VPT for short-courses (24 to 60 hours) compared to patients receiving extended-courses (72 hours to 7 days). Methods: This was a retrospective cohort study comparing the incidence of AKI in noncritically ill patients receiving VPT for short and extended durations between January 2016 and August 2018. Fishers exact tests were used for differences in nominal data between groups and Mann-Whitney U tests were used for continuous data. Results: Of the 2567 screened, 154 patients were included in the short-course group and 106 were included in the extended-course group. The incidence of AKI for patients in the short-course group was 12% (19/154) versus 26% (28/106) in the extended-course group (odds ratio: 2.55, 95% CI: 1.33-4.87; P =.004). Conclusion: In noncritically ill patients, a short-course of VPT experienced less AKI compared to an extended-course. Clinicians should continue to practice strict antimicrobial stewardship for VPT therapies expected to continue beyond 72 hours. [ABSTRACT FROM AUTHOR]

Most purulent orofacial infections are of odontogenic origin. It is well established that odontogenic infections are polymicrobial in nature. Empiric antibiotics were administered before the culture and sensitivity test results were obtained and specific antibiotics were administered based on the culture and sensitivity test results. But resistance was a challenging problem all throughout along with development of more virulent strains of microorganisms which were more infectious and resistant to many known antibiotics. Objective: To identify the causative aerobic and anaerobic micro-organisms responsible for orofacial infections and to evaluate the resistance against empirical antibiotics used in the treatment of space infections. Method: 142 patients with head and neck fascial space infections of odontogenic origin were randomly taken, the pus samples and aspirates were collected aseptically from patients for aerobic and anaerobic microbiological study. Results: In this study the most common aerobic organism isolated was streptococcus viridians (34.49%), most common anaerobe was peptostreptococci, (61.11%) and the most common mixed organism was streptococcus with peptostreptococci (30%). Amoxicillin was the most commonly used empirical drug in all cases and showed highest resistance (96.55%) for all the organisms. But linezolid (100%) was sensitive to all the aerobic, anaerobic and mixed group of organisms. Metronidazole (100%) turned out to be sensitive to the entire anaerobic group. Clindamycin (100%) appeared sensitive to the entire aerobic group. Conclusion: Knowledge about the pathologic flora involved in head and neck infection in a locality and their sensitivity and resistance to commonly used antibiotics will help the clinician in administering appropriate antibiotics.

Abstract Background Necrotizing fasciitis is a rare soft tissue infection characterized by rapid progressive necrosis with relative sparing of underlying muscles. This case is reported to highlight the emergence of multidrug resistant microbes in recent days which limits the use of empiric antibiotic therapy and necessitates early cultures and sensitivity enabling targeted antibiotic therapy. Factors that lead to antimicrobial resistance especially in sub-Saharan Africa have also been discussed. Case presentation We report the case of a 52-year-old black man who was referred to our centre for the management of cellulitis and suppurating ulcers of the right leg which had progressed to a wet gangrene. Following physical examination and work-up, a diagnosis of fulminant necrotizing fasciitis of the right leg caused by multidrug resistant Proteus mirabilis and Escherichia coli was made. Despite the broad-spectrum empiric antibiotic therapy and aggressive multiple surgical debridement, necrosis progressed leading to an above-knee amputation. Conclusion Necrotizing fasciitis is a surgical emergency that requires prompt diagnosis and aggressive surgical debridement in order to reduce morbidity and mortality. The emergence of multidrug resistant organisms in recent days have limited the use of empiric antibiotic therapy, necessitating early culture and sensitivity and the use of susceptibility-guided antibiotic therapy. Timely action to control the use of antibiotics in sub-Saharan Africa will reduce multidrug resistance and delay the arrival of post-antibiotics era.

Clinical characteristics of bacteremic urinary tract infection due to third-generation cephalosporin-resistant Escherichia coli in children remain unclear. We conducted a case control study comparing the clinical information of the third-generation cephalosporin-susceptible group (S- E. coli group) and the third-generation cephalosporin-resistant group (R- E. coli group). The R-E. coli group included extended-spectrum beta-lactamases (ESBLs) or AmpC-producing E. coli. We identified 52 cases of bacteremic UTI due to E. coli ; 42 cases were in the S-E. coli group and 10 cases were in the R-E. coli group. Empiric antibiotics were more likely to be inappropriate for pediatric patients with bacteremic urinary tract infection due to third-generation cephalosporin-resistant E. coli than those infected by susceptible E. coli (60% vs. 0%, P < 0.001). However, duration of fever and rate of relapse were not significantly different. The outcomes of bacteremic UTI due to multidrug-resistant E. coli in children were satisfactory regardless of susceptibility to empiric antibiotics. [ABSTRACT FROM AUTHOR]

Patients with sepsis present across a spectrum of infection sites and severity of illnesses requiring complex decision making at the bedside as to when prompt antibiotics are indicated and which regimen is warranted. Many hemodynamically stable patients with sepsis and low acuity of illness may benefit from further work up before initiating therapy, whereas patients with septic shock warrant emergent broad-spectrum antibiotics. The precise empiric regimen is determined by assessing patient and epidemiological risk factors, likely source of infection based on presenting signs and symptoms, and severity of illness. Hospitals should implement quality improvement measures to aid in the rapid and accurate diagnosis of septic patients and to ensure antibiotics are given to patients in an expedited fashion after antibiotic order. [ABSTRACT FROM AUTHOR]

The evaluation of disease progression and onsite therapeutic care choices for community-acquired pneumonia (CAP) patients is vital for their well-being and the optimum utilization of healthcare resources. The current study was conducted to assess physicians’ adherence to clinical practice standards and antibiotic prescribing behavior for the treatment of CAP in older people. A prospective study that included 121 consecutive patients admitted for CAP was conducted at Kulim Hospital, Kedah, from March 2020 to August 2020. Medical records including demographic data, comorbidity, physical examination, laboratory or radiologic findings, and drugs used for the treatment of CAP were accessed from bed head tickets (BHT). The mean age for patients was 73.5 ± 6.2 years, 73 (60.3%) and 48 (39.6%) were males and females, respectively. Amoxicillin/clavulanate (19.8%) was the most prescribed antibiotic for non-severe pneumonia followed by ampicillin sodium/sulbactam sodium (6.6%), while in patients with severe CAP beta-lactam + beta lactamase inhibitors (BLIs) with a combination of macrolide were the most common antibiotics prescribed either in patients with (21.4%) or without co-morbidities (8.2%). The average length of stay in the hospital with severe pneumonia was 6–7 days for 23.9% of patients and < 5 days for 21.4% of patients. The duration of intravenous antibiotics in patients with severe pneumonia was 6–7 days for 32.2% of patients. The present findings revealed the adherence of antibiotic prescribing practices to the Malaysian National Antimicrobial Guideline 2019 for CAP therapy among geriatric patients and adherence to the CAP criteria for hospital admissions.

Gram-negative organisms (GNOs) have increasing resistance rates to levofloxacin at Virginia Commonwealth University Health System (VCUHS), where levofloxacin is the most common agent added to provide double coverage of gram-negative infections. The goal of this study was to determine the adequacy of empiric gram-negative coverage for septic patients at our institution. A retrospective review of patients admitted to VCUHS, from January 1, 2014, to December 31, 2014, with a diagnosis of sepsis, severe sepsis, or septic shock and documented infection, was performed to determine the adequacy of various empiric antibiotic combinations. Of 219 patients who met the inclusion criteria, 56% of patients received monotherapy and 21% of patients received combination therapy (2 antibiotics) covering GNOs. GNOs (84%) were susceptible to piperacillin-tazobactam. When used in combination with cefepime and meropenem, levofloxacin did not increase coverage. However, levofloxacin provided an 8% increase in coverage and gentamicin provided an additional 13% increase in coverage, respectively, when used in combination with piperacillin-tazobactam. Among septic patients at VCUHS, gentamicin provided increased gram-negative coverage when compared with levofloxacin. Although susceptibility to piperacillin-tazobactam alone was relatively low, the combination of piperacillin-tazobactam and gentamicin provided nearly equivalent coverage to meropenem and gentamicin. [ABSTRACT FROM AUTHOR]

Background Physicians face competing demands of maximizing pathogen coverage while minimizing unnecessary use of broad-spectrum antibiotics when managing sepsis. We sought to identify physicians' perceived likelihood of coverage achieved by their usual empiric antibiotic regimen, along with minimum thresholds of coverage they would be willing to accept when managing these patients. Methods We conducted a scenario-based survey of internal medicine physicians from across Canada using a 2 × 2 factorial design, varied by infection source (undifferentiated vs genitourinary) and severity (mild vs severe) denoted by the Quick Sequential Organ Failure Assessment (qSOFA) score. For each scenario, participants selected their preferred empiric antibiotic regimen, estimated the likelihood of coverage achieved by that regimen, and considered their minimum threshold of coverage. Results We had 238 respondents: 87 (36.6%) residents and 151 attending physicians (63.4%). The perceived likelihood of antibiotic coverage and minimum thresholds of coverage (with interquartile range) for each scenario were as follows: (1) severe undifferentiated, 90% (89.5%–95.0%) and 90% (80%–95%), respectively; (2) mild undifferentiated, 89% (80%–95%) and 80% (70%–89.5%); (3) severe genitourinary, 91% (87.3%–95.0%) and 90% (80.0%–90.0%); and (4) mild genitourinary, 90% (81.8%–91.3%) and 80% (71.8%–90%). Illness severity and infectious disease specialty predicted higher thresholds of coverage whereas less clinical experience and lower self-reported prescribing intensity predicted lower thresholds of coverage. Conclusions Pathogen coverage of 80% and 90% are physician-acceptable thresholds for managing patients with mild and severe sepsis from bacterial infections. These data may inform clinical guidelines and decision-support tools to improve empiric antibiotic prescribing. [ABSTRACT FROM AUTHOR]

Neonates in the intensive care unit diagnosed with suspected early onset neonatal sepsis are common. Empiric antibiotic therapy is crucial for the management of early onset neonatal sepsis. The purpose of this study was to describe the empiric antibiotic de-escalation practice in suspected early onset neonatal sepsis and evaluate its outcome within 7 days of birth. This was a single centre study conducted at a Malaysian tertiary hospital where new-borns were admitted to the hospital within 72 h of birth and prescribed with an empiric antibiotic therapy were included. Relevant data were retrieved from the patients' electronic medical records. A total of 529 new-borns were screened and 278 (mean gestational age- 34.9±3.73 weeks, birth weight- 2.34±0.87 kg) were included. Common maternal risk factors of early onset neonatal sepsis identified were prolonged rupture of membranes (>18 h), positive culture of the maternal high vaginal swab and meconium- stained amniotic fluid. Majority of patients presented with respiratory symptoms and empiric antibiotics, namely crystalline penicillin and gentamicin were started within 24 h of birth. The early empirical antibiotic de-escalation was practiced in 98.5 % of patients; of these, 59 % had aminoglycoside withdrawal after the second dose and continuation of crystalline penicillin as a monotherapy (de-escalation group I). The remaining patients had complete antibiotic withdrawal prior to 72 h of exposure (de-escalation group II). New-borns in the de-escalation group I had significantly longer treatment duration and poor Apgar scores at 1 mi of life (Apgar score ≤3; p<0.05). In addition, 6 patients had positive blood cultures and 2.2 % of patients were classified as treatment failure. Hence, an early antibiotic de-escalation may potentially be practiced in suspected early onset neonatal sepsis. [ABSTRACT FROM AUTHOR]

Background: In the ED, patients are treated empirically for suspected gonorrhea and/or chlamydia (GC). Limited studies have evaluated the treatment of sexually transmitted diseases (STDs) in conjunction with predictor variables. This study will allow providers to better identify patients with potential GC to streamline antibiotic treatment.Objectives: The primary objective was to determine the incidence of positive assay in patients that underwent GC screening. The secondary objectives included the proportion of patients assayed that received empiric therapy and the predictive value of risk factors to identify positive assays.Methods: This retrospective cohort study included adult patients who presented to the health-system EDs and underwent GC screening. Subjects were excluded if they were victims of sexual assault, left AMA or eloped.Results: A total of 490 assayed patients were included, of which 84 (17%) were found to be positive for GC assay. Of the 278 patients treated empirically, 74% had a negative assay. Of the entire sample (n = 490), risk factors found to predict a positive assay (p < 0.05) included male, women <25 years of age, concomitant bacterial vaginosis, pelvic inflammatory disease or trichomonas, penile discharge, inconsistent condom use, previous/coexisting STDs, and uninsured.Conclusions: Compared to previous reports, this study found a higher incidence of positive GC assays for patients with suspected infection. This is the first study to evaluate GC testing in both men and women in the ED, and risk factors not previously reported by the CDC were identified. [ABSTRACT FROM AUTHOR]

Purpose: It is critical to engage ED providers in antimicrobial stewardship programs (ASP). Emergency medicine pharmacists (EMPs) play an important role in ASP by working with providers to choose empiric antimicrobials. This study aimed to determine the impact of an EMP on appropriate empiric antibiotic prescribing for community-acquired pneumonia (CAP) and intra-abdominal infections (CA-IAI).Methods: A retrospective cohort study was conducted evaluating adult patients admitted with CAP or CA-IAI. The primary outcome of this study was to compare guideline-concordant empiric antibiotic prescribing when an EMP was present vs. absent. We also aimed to compare the impact of an EMP in an early-ASP vs. established-ASP.Results: 320 patients were included in the study (EMP n = 185, no-EMP n = 135). Overall empiric antibiotic prescribing was more likely to be guideline-concordant when an EMP was present (78% vs. 61%, p = 0.001); this was true for both the CAP (95% vs. 79%, p = 0.005) and CA-IAI subgroups (62% vs. 44%, p = 0.025). Total guideline-concordant prescribing significantly increased between the early-ASP and established-ASP (60% vs. 82.5%, p < 0.001) and was more likely when an EMP was present (early-ASP: 68.3% vs. 45.8%, p = 0.005; established-ASP: 90.5% vs. 73.7%, p = 0.005). Patients receiving guideline-concordant antibiotics in the ED continued appropriate therapy upon admission 82.5% of the time vs. 18.8% if the ED antibiotic was inappropriate (p < 0.001).Conclusion: The presence of an EMP significantly improved guideline-concordant empiric antibiotic prescribing for CAP and CA-IAI in both an early and established ASP. Inpatient orders were more likely to be guideline-concordant if appropriate therapy was ordered in the ED. [ABSTRACT FROM AUTHOR]

Most purulent orofacial infections are of odontogenic origin. It is well established that odontogenic infections are polymicrobial in nature. Empiric antibiotics were administered before the culture and sensitivity test results were obtained and specific antibiotics were administered based on the culture and sensitivity test results. But resistance was a challenging problem all throughout along with development of more virulent strains of microorganisms which were more infectious and resistant to many known antibiotics. To identify the causative aerobic and anaerobic micro-organisms responsible for orofacial infections and to evaluate the resistance against empirical antibiotics used in the treatment of space infections. 142 patients with head and neck fascial space infections of odontogenic origin were randomly taken, the pus samples and aspirates were collected aseptically from patients for aerobic and anaerobic microbiological study. In this study the most common aerobic organism isolated was streptococcus viridians (34.49%), most common anaerobe was peptostreptococci, (61.11%) and the most common mixed organism was streptococcus with peptostreptococci (30%). Amoxicillin was the most commonly used empirical drug in all cases and showed highest resistance (96.55%) for all the organisms. But linezolid (100%) was sensitive to all the aerobic, anaerobic and mixed group of organisms. Metronidazole (100%) turned out to be sensitive to the entire anaerobic group. Clindamycin (100%) appeared sensitive to the entire aerobic group. Knowledge about the pathologic flora involved in head and neck infection in a locality and their sensitivity and resistance to commonly used antibiotics will help the clinician in administering appropriate antibiotics. [ABSTRACT FROM AUTHOR]

• Machine learning-based models for predicting antibiotic non-susceptibility were developed to support the decision on the selection of empiric antibiotics to treat suspected hospital-acquired urinary tract infections. • A personalised insusceptibility estimator for clinical application was also developed and validated with specific patient scenarios. Prediction of antibiotic non-susceptibility based on patient characteristics and clinical status may support selection of empiric antibiotics for suspected hospital-acquired urinary tract infections (HA-UTIs). Prediction models were developed to predict non-susceptible results of eight antibiotic susceptibility tests ordered for suspected HA-UTI. Eligible patients were those with urine culture and susceptibility test results after 48 hours of admission between 2010–2021. Patient demographics, diagnosis, prescriptions, exposure to multidrug-resistant organisms, transfer history, and a daily calculated antibiogram were used as predictors. Lasso logistic regression (LLR), extreme gradient boosting (XGB), random forest, and stacked ensemble methods were used for development. Parsimonious models were also developed for clinical utility. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC). In 10 474 suspected HA-UTI cases, the mean age was 62.1 ± 16.2 years and 48.1% were male. Non-susceptibility prediction for ampicillin/sulbactam, cefepime, ciprofloxacin, imipenem, piperacillin/tazobactam, and trimethoprim/sulfamethoxazole performed best using the stacked ensemble (AUROC 76.9, 76.1, 77.0, 80.6, 76.1, and 76.5, respectively). The model for ampicillin performed best with LLR (AUROC 73.4). Extreme gradient boosting only performed best for gentamicin (AUROC 66.9). In the parsimonious models, the LLR yielded the highest AUROC for ampicillin, ampicillin/sulbactam, cefepime, gentamicin, and trimethoprim/sulfamethoxazole (AUROC 70.6, 71.8, 73.0, 65.9, and 73.0, respectively). The model for ciprofloxacin performed best with XGB (AUROC 70.3), while the model for imipenem performed best in the stacked ensemble (AUROC 71.3). A personalised application using the parsimonious models was publicly released. Prediction models for antibiotic non-susceptibility were developed to support empiric antibiotic selection for HA-UTI. [ABSTRACT FROM AUTHOR]

Objective: The empiric use of antibiotics for elevated prostate specific antigen (PSA) is practiced by many urologists worldwide. This study aims to investigate the effect of antibiotics on the degree of PSA change, linking it with histopathology results. Materials and Methods: This is a prospective randomized study. Patients presenting with a high PSA were randomized into two groups. Group 1 received antibiotics for a period of 4 weeks, while Group 2 did not receive any antibiotics. Both groups had repeated samples of PSA measured 6 weeks from their initial presentation. All patients underwent transrectal ultrasound-guided biopsy of the prostate. Results of PSA measurements and the degree of change were correlated with results of histopathology. Results: Eighty-four patients completed the study. Their mean age±standard deviation was 66.8 ± 6.9 years. Group 1 included 44 patients, while Group 2 included 42 patients. Prostate cancer (PCa) was detected in 50% and 35.7% of Group 1 and Group 2 patients, respectively (p = 0.52). No statistically significant difference in the mean change in PSA level (Δ PSA) between both groups was noted (p = 0.54). In Group 1, a more significant lowering of PSA was documented in PCa than in non-PCa patients (p = 0.008). No statistically significant relationship between Δ PSA and Gleason score in both groups was present. Conclusion: The empiric use of antibiotics does not hold any benefit for patients presenting with an elevated PSA. Also, the degree of change in PSA does not correlate with results of transrectal ultrasound-guided biopsy of the prostate.

Study Objective: The combination of cefepime and vancomycin is commonly used as an empiric antimicrobial regimen. Time to first-dose antibiotics is associated with survival benefit. The objective of this study is to evaluate whether cefepime intravenous push (IVP) is associated with a shorter time to vancomycin administration in the emergency department (ED) compared with cefepime intravenous piggyback (IVPB) infusion. Methods: This was a retrospective chart review of records of patients who were treated with the vancomycin–cefepime combination in the ED. Results: A total of 1071 charts from April 2013 to January 2015 were reviewed. Included in the pre-(IVBP) group was 536 subjects and 535 subjects in the post-(IVP) group. The indications for antibiotic therapy were sepsis alone (28.3%), pneumonia alone (30.7%), sepsis with pneumonia (36.5%), and other (4.6%). The median time from administration of cefepime to vancomycin were 63.5 minutes and 2.0 minutes in the IVPB and IVP cohorts, respectively (P < .001). Conclusion: The use of first-dose cefepime IVP in the ED resulted in a statistically significant decrease in time to vancomycin administration of over 1 hour. [ABSTRACT FROM AUTHOR]

Purpose of Review: Organism identification and antibiotic selection remain a critical component of periprosthetic joint infection (PJI) treatment. Prior to organism identification and/or the availability of antibiotic sensitivities, empiric antibiotics are routinely started. A basic understanding of a region or institutions antibiogram is paramount for selection of an empiric treatment regimen. Evolving antibiogram results and regional antibiotic resistance are important to follow as this may change antibiotic selection in some patient populations.Recent Findings: The Clinical Laboratory and Standards Institute (CLSI) has created guidelines and standards for the creation and maintenance of antibiograms that should be followed by institutions. The infecting organism during PJI may be different in acute vs chronic infections and empiric therapy may change depending on the timing. Antibiotic prophylaxis for major procedures in certain patient populations should be critically evaluated based on regional and national antibiogram results.Summary: The CLSI guides recommendations and antibiotic resistance testing techniques and should be consulted when creating an antibiogram. The local and regional antibiogram should be consulted prior to administration of empiric and prophylactic antibiotics. [ABSTRACT FROM AUTHOR]

Introduction:The significant pathogens in acute epiglottitis (AE) are poorly defined in the postHaemophilus influenzatype b-vaccine era. Furthermore, there is a lack of clinical evaluations of antibiotic regimens in patients with AE. We aimed to evaluate the effectiveness of empiric intravenous ampicillin in the treatment of patients with AE. Materials & methods:All patients admitted with AE to the Ear-Nose-Throat Department, Aarhus University Hospital, Denmark, from 2001 to 2015 were included. Results:In total, 103 (51 males) patients were included in the study. The median duration of hospitalization was four days. There was no statistical significant difference between patients initially treated with intravenous ampicillin (n = 83) or other antibiotics (n = 20) (p = .26). The antibiotic regimen was altered during admission in 11% of patients, without significant difference between antibiotic groups (ampicillin 10% vs non-ampicillin 15%,p = .44). Complications potentially related to insufficient antibiotic treatment were observed in four (5%) patients initially treated with ampicillin, but in none of the patients initially treated with antibiotics other than ampicillin (p = 1.00). Throat swab cultures and blood cultures frequently yielded negative results. Conclusions:Intravenous ampicillin is efficient as empiric antibiotic therapy for AE patients, leading to a quick recovery and low complication rates. [ABSTRACT FROM PUBLISHER]

Objective The objective of this study was to determine the clinical impact of time to antibiotic administration in adult inpatients who have hematologic malignancies and develop febrile neutropenia. Methods A retrospective chart review was conducted to screen for all febrile neutropenia events amongst adult hematologic malignancy patients between 1 January 2010 and 1 September 2014. All included patients were admitted to the hospital at the time of fever onset, having been admitted for a diagnosis other than febrile neutropenia. Descriptive statistics and logistic generalized estimated equations were used to analyze the data. Results Two hundred forty-four neutropenic fever events met inclusion criteria. Thirty-five events (14.34%) led to negative clinical outcomes (in-hospital mortality, intensive care unit transfer, or vasopressor requirement), with an in-house mortality rate of 7.4%. The time to antibiotics ranged from 10 min to 1495 min. The median time to antibiotics in the events that led to negative outcomes was 120 min compared to 102 min in the events that did not lead to the negative outcome (p = 0.93). Conditional order sets were used to order empiric antibiotics in 176 events (72.1%) and significantly reduced time to antibiotics from 287 min to 143 min (p = 0.0019). Conclusion Prolonged time to antibiotic administration in hematologic malignancy patients who develop neutropenic fever was not shown to be associated with negative clinical outcomes. [ABSTRACT FROM AUTHOR]

Introduction Up until 2010, the recommended duration of empiric broad-spectrum antibiotics for febrile neutropenia was until absolute neutrophil count (ANC) recovery. An updated guideline on the use of antimicrobial agents in neutropenic patients with cancer indicates that patients who have completed an appropriate treatment course of broad-spectrum antibiotics, with resolution of signs and symptoms of infection but persistent neutropenia, can be de-escalated to oral fluoroquinolone prophylaxis until ANC recovery. Methods The primary objective of this retrospective investigation was to evaluate the safety and efficacy of de-escalating broad-spectrum antibiotics in patients remaining neutropenic after at least 14 days of empiric broadspectrum antibiotics for febrile neutropenia compared to patients continuing broad-spectrum antibiotics until ANC recovery. Results There were 16 patients (61.5%) in the comparator group who met the primary endpoint of remaining afebrile and without escalation of antibiotics for at least 72 hours after 14 days of broad-spectrum antibiotics and 21 patients (80.7%) in the de-escalation group who met the primary endpoint of remaining afebrile and without reinitiation of broad-spectrum antibiotics for at least 72 hours after de-escalation to levofloxacin therapy (p = 0.11). Mean total duration of broad-spectrum antibiotic therapy was 23.5 ± 1.5 days in the comparator group versus 22.2 ± 1.43 days in the de-escalation group (p = 0.39). Conclusions Results of this investigation indicate that broad-spectrum antibiotics can be safely de-escalated to levofloxacin prophylaxis prior to ANC recovery in select patients. This practice may decrease the duration of broad-spectrum antibiotic exposure and associated complications. [ABSTRACT FROM AUTHOR]

Objective The empiric use of antibiotics for elevated prostate specific antigen (PSA) is practiced by many urologists worldwide. This study aims to investigate the effect of antibiotics on the degree of PSA change, linking it with histopathology results. Materials and Methods This is a prospective randomized study. Patients presenting with a high PSA were randomized into two groups. Group 1 received antibiotics for a period of 4 weeks, while Group 2 did not receive any antibiotics. Both groups had repeated samples of PSA measured 6 weeks from their initial presentation. All patients underwent transrectal ultrasound-guided biopsy of the prostate. Results of PSA measurements and the degree of change were correlated with results of histopathology. Results Eighty-four patients completed the study. Their mean age ± standard deviation was 66.8 ± 6.9 years. Group 1 included 44 patients, while Group 2 included 42 patients. Prostate cancer (PCa) was detected in 50% and 35.7% of Group 1 and Group 2 patients, respectively ( p = 0.52). No statistically significant difference in the mean change in PSA level (Δ PSA) between both groups was noted ( p = 0.54). In Group 1, a more significant lowering of PSA was documented in PCa than in non-PCa patients ( p = 0.008). No statistically significant relationship between Δ PSA and Gleason score in both groups was present. Conclusion The empiric use of antibiotics does not hold any benefit for patients presenting with an elevated PSA. Also, the degree of change in PSA does not correlate with results of transrectal ultrasound-guided biopsy of the prostate. [ABSTRACT FROM AUTHOR]

Summary Objectives To describe the aetiology, risk factors, treatment and outcome of children with community-onset invasive bacterial infections (IBI) and determine the appropriateness of the nationally recommended empiric antibiotic therapy in children with non-oncological comorbidities. Method The CABIN network prospectively collected clinical information for all positive blood and cerebrospinal fluid cultures in children aged 1 month to 15 years in southwest London over three years. Results During 2009–11, 119 healthy children each had a single IBI episode and 61 children with non-oncological comorbidities had 83 IBI episodes. The pathogens causing IBI in children with comorbidities and no central venous catheter (CVC) were similar to those causing IBI in healthy children. However, those with a CVC had multiple IBI episodes, often with pathogens usually associated with nosocomial infection. In particular, gastro-intestinal commensals were frequently responsible for IBI in TPN-dependent children with gastro-intestinal disease (16/43 episodes) and those with liver disease (8/43). Nationally recommended antibiotics were commenced empirically in 93%, with additional or alternate antibiotics more likely to be prescribed in children with comorbidities or those requiring intensive care. Fifteen children died (11 healthy, 4 with comorbidity), including 12 who died before arrival or in the Emergency Department. Conclusion Increasing care of children with comorbidities in the community has resulted in a significant proportion of community-onset IBI occurring in this group. Children with a CVC in situ – particularly those with gastro-intestinal and liver disease – were infected with a wider range of potentially more virulent pathogens. They might benefit from more broad-spectrum antimicrobial cover. [ABSTRACT FROM AUTHOR]

Febrile neutropenia (FN) can occur at any time during the course of a malignancy, especially hematologic malignancies, from diagnosis to end-stage disease. The majority of FN episodes are typically confined to the period of initial diagnosis and active treatment. Because of suppressed inflammatory responses, fever is often the sole sign of infection. As FN is a true medical emergency, prompt identification of and intervention in FN can prolong survival and improve quality of life. This article reviews FN in the setting of hematologic malignancies, specifically myelodysplastic syndromes and acute leukemias, providing an overview of the definition of fever and neutropenia, diagnostic approach, categories of risk/risk assessment, management in patients at low and high risk, and prophylaxis of infections. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Ventilator-associated pneumonia (VAP) occurs in up to 25% of mechanically ventilated patients, with an associated mortality up to 50%. Early diagnosis and appropriate empiric antibiotic coverage of VAP are crucial. Given the multitude of noninfectious clinical and radiographic anomalies within trauma patients, microbiology from bronchioalveolar lavage (BAL) is often needed. Empiric antibiotics are administered while awaiting BAL culture data. Little is known about the effects of these empiric antibiotics on patients with negative BAL microbiology if a subsequent VAP occurs during the same hospital course. Methods: This is a retrospective chart review of intubated trauma patients undergoing BAL for suspected pneumonia over a 3-y period at a Level 1 trauma center. All patients with suspected VAP undergoing a BAL receive empiric antibiotics. If microbiology data are negative at 72 h, all antibiotics are stopped; however, if the BAL returns with ≥105 colony-forming units per milliliter, the diagnosis of VAP is confirmed. We divided patients into three groups. Group 1 consisted of patients in whom the initial BAL was positive for VAP. Group 2 consisted of patients with an initial negative BAL, who subsequently developed VAP at a later point in the hospital course. Group 3 consisted of patients with negative BAL who did not develop a subsequent VAP. Results: We obtained 499 BAL specimens in 185 patients over the 3-y period. A total of 14 patients with 23 BAL specimens initially negative for VAP subsequently developed VAP later during the same hospital stay. These patients did not have an increase in the hospital length of stay, intensive care unit days, ventilator days, or mortality compared with those who had a positive culture on the first suspicion of VAP. There was a significant increase in the percentage of Enterobacter (21% versus 8%) and Morganella (8% versus 0%) as the causative organism in these 14 patients when the VAP occurred. Furthermore, the profile of the top two organisms in each group changed. Enterobacter (21%) and Pseudomonas (17%) were the principal organisms in the initial BAL-negative group, whereas the two predominant strains in the initial positive BAL group were methicillin-sensitive Staphylococcus aureus (21%) and Haemophilus influenza (11%). Interestingly, methicillin-resistant S. aureus remained the third most common organism in both groups. Empiric antibiotics also did not seem to induce the growth of multidrug-resistant organisms, and there was no increased rate of secondary infections such as Clostridium difficile. Conclusions: Ventilator-associated pneumonia remains a significant cause of morbidity and mortality in mechanically ventilated trauma patients. The diagnosis and treatment of VAP continue to be challenging. Once clinically suspected, empiric coverage decreases morbidity and mortality. Our data demonstrate that patients who receive empiric coverage exhibit a significantly different microbiologic profile compared with those who had an initial positive BAL culture. Initial empiric antibiotics in BAL-negative patients were not associated with an increase in multidrug-resistant organisms, hospital, or intensive care unit length of stay, ventilator days, and mortality or secondary infections. [Copyright &y& Elsevier]

The article presents a study which examines the use of antiobiotic de-escalation in patients with hospital-acquired severe sepsis. It is inferred that 169 patients with 216 episodes of severe sepsis in an intensive care unit were assessed. According to the study, de-escalation was effective in less than 50 percent of the cases despite close collaboration among intensivists and infectious disease specialists.

Medically inappropriate, ineffective and economically inefficient use of antimicrobials is commonly observed in the health care units throughout the world especially in the developing countries. Antimicrobial stewardship programs attempt to balance the demand for these life-saving drugs with the need to preserve their future efficacy. A comprehensive evidence-based stewardship program should include elements chosen from the recommendations based on local antimicrobials use and resistance problems and on available resources that may differ, depending on the size of the institution or clinical setting. For success of antibiotic stewardship it is essential to increase awareness amongst medical professionals. Discipline in antimicrobial prescribing is most vital in clinical settings. A careful assessment of the benefits of prescribing against the risk of non-prescribing of antibiotics should be considered. It should be an endeavor of every physician to justify antibiotic prescription in case of empirical use. Integration of advanced information technology into antimicrobial stewardship programs holds the potential to both reduce antimicrobial overuse and improve outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To examine the predictive validity of prior cultures at predicting the microorganism isolated at the time of suspicion of ventilator-associated pneumonia (VAP). Materials and Methods: We performed a retrospective analysis of a randomized controlled trial of different diagnostic and antibiotic strategies. In a subset of patients with pre-enrollment cultures, we examined agreement between cultures 1 to 3 days before suspicion of VAP and enrollment cultures performed on the day of suspicion of VAP and potential antibiotic error rates (estimated using the equation 1 − crude agreement). Results: Two hundred eighty-one (39%) of 739 patients had pre-enrollment culture. One hundred thirty (46%) of 281 yielded a pathogenic microorganism. In patients with positive pre-enrollment cultures, crude agreement was 0.63 (95% confidence interval, 0.55-0.71) for organism, 0.84 (0.77-0.89) for Gram class, and 0.61 (0.52-0.69) for species with sensitivity. Potential antibiotic error rates ranged from 16% (11%-33%) to 39% (31%-48%). Better agreement (P = .033) occurred in isolates from patients receiving new antibiotics during the surveillance period (0.78 [0.64-0.87]) compared to those not on antibiotics (0.58 [0.45-0.69]), or on no new antibiotics (0.50 [0.32-0.68]). Conclusions: There is poor agreement between prior cultures and cultures performed at time of suspicion of VAP. Prior cultures should not be used to narrow the spectrum of empiric antibiotics. [Copyright &y& Elsevier]

Ventilator-associated pneumonia (VAP) is the most common infectious complication in patients receiving mechanical ventilation and accounts for exorbitant use of resources in the intensive care unit. Antimicrobial management of VAP incorporates an initial broad-spectrum, empiric regimen to ensure appropriate coverage with deescalation of therapy after 48-72 hours based on culture results and sensitivities. When VAP clinically responds to treatment, antimicrobials should be discontinued after 7-8 days to reduce overall antibiotic consumption and the selection pressure on flora observed in the intensive care unit and thus minimize the development and spread of antimicrobial resistance. [ABSTRACT FROM AUTHOR]

The evaluation of disease progression and onsite therapeutic care choices for community-acquired pneumonia (CAP) patients is vital for their well-being and the optimum utilization of healthcare resources. The current study was conducted to assess physicians' adherence to clinical practice standards and antibiotic prescribing behavior for the treatment of CAP in older people. A prospective study that included 121 consecutive patients admitted for CAP was conducted at Kulim Hospital, Kedah, from March 2020 to August 2020. Medical records including demographic data, comorbidity, physical examination, laboratory or radiologic findings, and drugs used for the treatment of CAP were accessed from bed head tickets (BHT). The mean age for patients was 73.5 ± 6.2 years, 73 (60.3%) and 48 (39.6%) were males and females, respectively. Amoxicillin/clavulanate (19.8%) was the most prescribed antibiotic for non-severe pneumonia followed by ampicillin sodium/sulbactam sodium (6.6%), while in patients with severe CAP beta-lactam + beta lactamase inhibitors (BLIs) with a combination of macrolide were the most common antibiotics prescribed either in patients with (21.4%) or without co-morbidities (8.2%). The average length of stay in the hospital with severe pneumonia was 6–7 days for 23.9% of patients and < 5 days for 21.4% of patients. The duration of intravenous antibiotics in patients with severe pneumonia was 6–7 days for 32.2% of patients. The present findings revealed the adherence of antibiotic prescribing practices to the Malaysian National Antimicrobial Guideline 2019 for CAP therapy among geriatric patients and adherence to the CAP criteria for hospital admissions. [ABSTRACT FROM AUTHOR]